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Community TB Care

Community TB Care. Making DOTS More Accessible. Why Community TB Care Initiative Was Needed. Sub-Saharan Africa has some of the highest TB case rates in the world, Countries with high prevalence for HIV, have experienced huge increases in notified TB cases,

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Community TB Care

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  1. Community TB Care Making DOTS More Accessible Dr C Davis, SOTA 2002, June 10-14, 2002

  2. Why Community TB Care Initiative Was Needed • Sub-Saharan Africa has some of the highest TB case rates in the world, • Countries with high prevalence for HIV, have experienced huge increases in notified TB cases, • Traditional TB treatment policies - focused on hospital Rx during intensive phase - Health workers deliver TB treatment Dr C Davis, SOTA 2002, June 10-14, 2002

  3. Why Community TB Care Needed - Congestion in hospital wards and medical departments - Overstretched resources (I.e. human, material, financial) - Patient dissatisfaction with long separation from family Dr C Davis, SOTA 2002, June 10-14, 2002

  4. Dynamics of TB and HIV in Kenya 190 30 TB 170 25 HIV national 150 HIV Nairobi 20 130 TB incidence/100,000 HIV pevalence adults (%) 15 110 10 90 5 70 50 0 1975 1980 1985 1990 1995 2000 Dr C Davis, SOTA 2002, June 10-14, 2002

  5. PILOTING THE COMMUNITY TB CARE INITIATIVE • WHO in collaboration with partners (CDC, USAID, IUATLD, KNCV, UNAIDS) implemented some operations research • Objective was to evaluate the effectiveness, acceptability, affordability, and cost-effectiveness of community-based TB care • Eight district based projects developed in six countries (Botswana, Kenya, Malawi, South Africa, Uganda and Zambia). Study from 1998-2000 Dr C Davis, SOTA 2002, June 10-14, 2002

  6. KEY FEATURES OF THE COMMUNITY TB CARE PILOT PROJECTS

  7. EVIDENCE FROM THE PILOT SITES GUGULETU, SOUTH AFRICA • Designed to evaluate program performance and cost-effectiveness of various supervision options (clinic, community and other) for TB treatment. Major findings: -TB treatment outcomes were better for community supervised TB treatment, - Community supervision of treatment is more cost effective than wholly clinic based supervision Dr C Davis, SOTA 2002, June 10-14, 2002

  8. TREATMENT OUTCOMES FOR GUGULETU, SOUTH AFRICA SITE Treatment outcomes for new smear positive TB cases Outcome Clinic DOTCommunity Other* (n=338) (n=331) (n=54) Cured 49% 70% Completed 9% 11% 68% Died 2% 1% 9% Defaulted 23% 14% 5% Transferred 17% 5% 17% Failure 0 < 1% *=workplace, home/self, school, hospital Patients treated under community DOT were significantly more likely to have treatment success than patients treated in the clinic (RR 1.4, 95% CI 1.2-1.5, P<0.001) Treatment outcomes for retreatment smear positive TB cases Outcome Clinic DOTCommunityOther (n=215) (n=29) (n=8) Cured 41% 63% 33% Completed 12% 10% 15% Died 8% 3% 19% Defaulted 29% 19% 22% Transferred 9% 3% 11% Failure 0 < 1% 0

  9. Guguletu, South Africa Dr C Davis, SOTA 2002, June 10-14, 2002

  10. EVIDENCE FROM THE PILOT SITES KIBOGA DISTRICT, UGANDA: • Study designed to compare the cost-effectiveness of community TB care to conventional hospital based care • Major findings: - Patients in the intervention group twice as likely to be treated successfully than those in the control group. - There were substantial reductions in cost and over 50% improvement in cost-effectiveness in the intervention group. - The approach was acceptable to patients, health care workers and the community. Major conclusion: Because of the success of this project, CB-DOTS has been adopted as a national policy since January 2000 Dr C Davis, SOTA 2002, June 10-14, 2002

  11. KIBOGA SITE Before CBDOT option (%) After CBDOT option (%) Treatment outcomes 1997 1998-9* Cured 76 (47.2) 166 (63.4) Completed treatment 19 (11.8) 28 (10.7) Failure 1 (0.6) 0 Died 25 (15.5) 37 (14.1) Interrupted treatment 31 (19.3) 4 (1.5) Transferred 9 (5.6) 27 (10.3) Total 161 262 Treatment success 95 (59) 194 (74) * Dr C Davis, SOTA 2002, June 10-14, 2002

  12. Cost-effectiveness, KIBOGA

  13. Lessons Learned From Pilot Sites • Community-based DOTS is feasible, acceptable, and cost-effective • Successful CTBC requires close collaboration with NTP and the community • Should only be implemented where there is a functioning NTP with the 5 elements of DOTS strategy in place • Managerial expertise is essential; ensuring the decentralization of logistics for TB control (e.g. drug supply, reporting outcomes etc) Dr C Davis, SOTA 2002, June 10-14, 2002

  14. Lessons Learned From Pilot Sites • Sustainability of the program must be planned from the start. A good situation analysis is required to identify appropriate community care providers. • Training and capacity building for the community structures are prerequisites for a successful CB-DOTS. • While CB-DOTS is more cost-effective, new resources are required for training of care providers, setting up systems, patient follow-up and supervision. • CTBC should complement and extend NTP capacity, not replace it. • Effective CB-DOTS requires a strong reporting system, access to lab facilities, and a secure drug supply. Dr C Davis, SOTA 2002, June 10-14, 2002

  15. Approaches To Promote Community TB Care Initiative in Africa • Community TB Care is one of the strategies for DOTS expansion in the WHO/AFRO Regional TB Control Strategic Plan (2001-2005) • Guidelines for implementation of CB-DOTS are in final draft • Scaling up of pilot projects within the countries concerned ( Kenya, Malawi, Uganda) • Promotion/Dissemination of lessons learned in CTBC Initiative through sub-regional Workshops (Nairobi May 6-10, 2002) Dr C Davis, SOTA 2002, June 10-14, 2002

  16. Thank You Dr C Davis, SOTA 2002, June 10-14, 2002

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